Is male promiscuity the main route of HIV/AIDS transmission in Africa?

Sexual transmission is considered to be the main source of the spread of the HIV/AIDS epidemic in Africa1.

The pervasive if unstated belief in the HIV/AIDS community is that males are primarily responsible for spreading the infection among married and cohabiting couples. A U.N. report entitled Women and HIV/AIDS: Confronting the Crisis reported: “Nearly universally, cultural expectations have encouraged men to have multiple partners, while women are expected to abstain or be faithful.” and “Faithfulness offers little protection to wives whose husbands have several partners or were infected before they were married.”

The evidence stems from the fact that most couples affected by HIV/AIDS in sub-Saharan Africa live in HIV-discordant or serodiscordant relationships, i.e. relationships in which only one of the two partners is HIV-positive while the other one is HIV-negative. Men are usually thought to be the partner who is HIV positive in most relationships, and most prevention campaigns are focused on men. A recent study fundamentally challenges the assumption that men are more likely to be the infected partner in a serodiscordant partnership.

The proportion of HIV-positive women in stable heterosexual serodiscordant relationships was 47% (95% CI 43-52) in 27 cohort studies enrolling 13,061 couples and 46% (CI 41-51) in Demographic and Health Survey data from 14 countries. Women are just as likely as men to be the HIV-positive partner in a discordant couple.

An earlier study from 5 African countries showed that in a sizeable proportion of HIV-infected couples only the woman is infected. The fraction of infected couples where only females are infected is between 30 and 40 percent; overall women are just as likely as men to be the HIV-positive partner in HIV-discordant partnerships.

These two sets of findings challenge the notion that males are the primary channel for HIV transmission from high-risk groups to the general population. They also contradict self-reports of sexual behavior by females. In the same surveys, during the last 12 months self-reported sexual intercourse outside the union among women in cohabiting couples ranges from 0.7 percent in Burkina Faso to 4.1 percent in Tanzania, and among cohabiting males from 8.7 percent in Burkina Faso to 25.9 percent in Cameroon. Substantial reporting biases in self-reported sexual behavior among men and women are common and have been documented.

Potential explanations for the sizeable portion of discordant couples where only the woman is infected, including polygyny (marriage to several wives), a bias in the coverage of the HIV testing in the survey, and earlier unions or infections before the current union. These explanations for the most part do not explain the data in these five countries.

In a sample limited to couples where the woman has been in only one union for 10 years or more —which should exclude most case of infections prior to the current union—the proportion of discordant female couples decreases, but only slightly, except in Ghana and Tanzania (table 2). The proportion of discordant female couples in Burkina Faso, Cameroon, and Kenya is still around a sizeable 30 percent of HIV-infected couples. The percentage of discordant female couples in Ghana and Tanzania decreases to 19.5 and 21.9 percent, respectively, which suggests that infection before marriage might explain some, but not all, of the cases of couples where only the woman is infected.

The proportion of discordant female couples is difficult to explain unless women are also sexually active outside the marriage (or cohabiting union).

Sexual intercourse among women outside the marriage (or cohabiting union) may be more common than reported. Or, even if infrequent, women may be more vulnerable to infection during these encounters, for example, because they are less likely to use condoms than single women and married men (a point I have documented in another study co-authored with Rachel Kline).The point of this explanation is not to “blame” cohabiting women or suggest they are as “guilty” as cohabiting men in transmitting HIV/AIDS. The fact that sexual intercourse can, in many cases, be forced on women, should certainly be kept in mind.

Whatever its causes, sexual intercourse outside the union among women increases their vulnerability to HIV/AIDS. Designing prevention efforts for this population of women will not be an easy task given the culture of silence around women’s sexuality in many African countries and the stigma attached to those, and women in particular, with HIV/AIDS.

But to ignore the role that female sexual activity outside the union plays, among the other channels, in the transmission of the epidemic, would be a disservice to women.

Comments

There could be also a feeling of betrayal, hence the women could be on a "Revenge" mission-"He thinks he is the only one who can do it?, Let me show him too"
In Kenya there have been a rising trend of use of lodgings during day time(1200-1400hrs)by young and middle aged couples, some of who are known to be married by a different partner other than the one they present with.
In the African setting, they male partner was principally the bread winner and hence was at liberty to do as he pleases and not be questioned.More and more households are being ran/supported by the female partners, who then feel, they can also go out to have "fun" as they are not dependent on the men.
A break in the cultural norms could be another major contributor and I would be interested in getting more info especially on this.

Damien,
Great post, I find these findings so interesting and so important.
Have you looked at difference in sero-discordance according to either the average age of the couple or relative to how long the couple has been in a stable relationship?
We know that women tend to get infected at a younger age than men, so we might see higher rates of female sero-discordance in newer couples rather than older couples. This might hint at a possible mechanism.
But of course if you don't, than that really challenges the self reported data of sexual activity outside of marriage.
Karen Grepin
http://www.karengrepin.com/

Karen,
Thanks for your comment and your suggestion. Table 2 does something similar to what you had in mind, I believe. In table 2, the sample is limited to marriages or unions where the woman has been in only one union and for at least 10 years in that union. By doing this I want to rule out as much as possible cases where the woman might have been infected from a previous union or before the current union. By construction, this also implies a sample of unions with older women, as you are suggesting.
As can be seen in table 2, the proportion of discordant female couples decreases, but only slightly, except in Ghana and Tanzania. The proportion of discordant female couples in Burkina Faso, Cameroon, and Kenya is still around a sizeable 30 percent of HIV-infected couples. The percentage of discordant female couples in Ghana and Tanzania decreases to 19.5 and 21.9 percent, respectively, which suggests that infection before marriage might explain some, but not all, of the cases of couples where only the woman is infected.
Best,
Damien

CULTURE AND HIV/AIDS IN AFRICA
Culture is the process by which a person becomes all,” according to Albert Camus, a French writer. Culture makes us who we are and gives us a sense of pride, identity and belonging.
Without culture, a society, even when perfect, is but chaos. But what if that culture has been adulterated to an extent that what remains of what we call African culture is a distorted mirage of the original culture? Some of our traditional practices have been blamed for everything that goes wrong in Africa. Modernisation viewed African culture as primitive and uncivilised; colonial religion trashed it as evil and demonic, egalitarians see it as a barrier to equal rights, philanthropists and development theorists think it is an impediment to development.
Education and religion were used as social transformative agents reconstructing culture to what we are today. Whether this is good or bad is neither here nor there. Let’s admit it, we lost our original tradition a long time ago and many people are caught in conflicts between tradition and modernity. It is indeed a huge dilemma to be both traditional and modern at the same time. Miniskirts and female trousers are viewed by some as disregard for our culture and yet in our original culture we only covered private areas. It was Islamitization of Africa, Arabic cultures and British missionaries who introduced long dresses, especially for women. Most of the conservative taboos we are stuck with were never part of African tradition. For instance, how is it taboo to discuss sex and sexuality issues with our children? Isn’t it risky that they learn these things from their peers and other people we don’t know or trust, especially these days of HIV?
In fact, many teenagers prefer to discuss sex and sexuality issues with people who introduced the subject to them than their parents. This begs the question: just who do we offend by breaching some of the little ridiculous taboos? Most African traditional practices are known for their sexual explicitness, which was meant to prepare teenagers for future life, marriage, birth and the passage from one stage of life to the next. In fact, sexual innuendos were inherent in traditional art such as dances, songs and drawings which are misinterpreted and undervalued elements in contemporary society. Ironically, sexual expressions regarded today as gratuitous and vulgar were employed for moral guidance. Expressions of sexuality were not casual, superficial or gratuitous in the African tradition. It had to do with the cycle of life and the importance of cycles and rites of passage. In the absence of the traditional social structures and the aunts and uncles who used to play the advisory role to teenagers, parents should step in and openly discuss reproductive health issues with their children.
What we call our tradition today bears no or little resemblance to true and original African tradition. Our lives have been reorganized. The languages we speak, the dress codes we adhere to, even the social norms and values we subscribe to have been altered. It is a purely new way of life detached from the original traditional way of life. Any defence or reference to some of these archaic cultural practices is a facade, especially in the face of the marauding HIV/AIDS pandemic, one of the greatest human catastrophes of our time.
Some social organization, patriarchal structures, religious beliefs, taboos including polygamy remain key socio-cultural barriers to HIV prevention and enjoyment of relationships. Stated candidly, some of the traditional ways of life are mainly problematic not only to the enjoyment of marriage and sex itself, but to the advancement of safe sex and ultimately preventing the spread of HIV. Very few people in this generation can make sense of these taboos, and I question our keeping them if we can’t make sense of them. Discarding risky practices doesn’t necessarily mean succumbing to Western cultural hegemony.
Tradition is meant for the people not the way round; that’s why it’s supposed to be dynamic, especially in the face of social challenges such as HIV/Aids. Desperate situations call for desperate measures, and indeed these times require us to dump some of those taboos in order to save people’s lives. Taboos were there to appease ancestors, who brought blessings such as rains, good harvests to the people etc. But times have changed; the climate change phenomenon is affecting weather and rainfall patterns, not our ancestors anymore. I guess those ancestors would be happier to see their people live longer than to see them dying every day in a futile bid to respect “taboos”. It is time our tradition and these taboos were framed within the conditions of a rapidly changing world, in which tradition is understood as a required context of action, rather than simply an obstacle. In fact, tradition and culture should be resources in the combat of HIV/Aids.
BY ABDULRAHMAN ABDU
YEHDI DIRECTOR HOTORO TSAMIYAR BOKA, P. O BOX 1207 KANO.

Although men are sometimes culturally encouraged to have multiple sex partners, women also engage in various sexual activities that may influence their chances of contracting HIV/AIDS, be exposed to violence and unwanted pregnancies. While men and women are exposed differently to HIV/AIDS, they are both strongly influenced by it. Oftentimes, a woman's role and position in society will determine her chances of contracting HIV/AIDS. A look at age asymmetries in sexual relationships and condom use would better the understanding of power relations between genders. Age asymmetries are also important factors in in sexual relationships, in addition to gender-based power differences. Therefore girls' abilities to negotiate safe sexual behaviours are oftentimes limited.
In South Africa, if a couple is estimated to be in a relationship and violence or sexual violence occurs, bystanders are unwilling to come to assist the woman in question. Oftentimes, if women sell sex publicly, it is acceptable to beat and rape her. Fish-for-Sex in Zambia also proves gender violence against women in need. Fishermen, for example, refuse to sell fish to a female trader if she does not accept to sexually engage with him.

Well, I suppose the issue is not so much as to which gender is having more sex than than the other but rather, which strategies are having a greater impact in as far as prevention is concerned. over time, however, I've come to be weary of certain research findings and whose interest they aim to serve. I believe that randomisation as a methodological research approach, which many NGOs have made fashionable, can be very misleading especially if results are extrapolated to assume other areas are like the small sampled ones. Since most prevention programmes target men, the greater lesson is that both men and women should be targeted equally in HIV/AIDS programs. Mechanisms should be devised to seriously identify which strategies are working, eliminate the non performing ones and improve coordination among organisations dealing with HIV/AIDS.

Thank you for your thoughtful comment.
I agree with you that what really matters is not to "measure" which gender engage more in risky behaviors, but more to find out which strategies are having a greater impact in reducing HIV transmission. I share your observation that most prevention programs target men and the point of my research is to stress that women should be included equally in HIV prevention programs.
As an aside, the results reported in the studies mentioned in the blog post do not come from a randomized evaluation. Rather, they come from comparing simple averages taken from nationally representative household surveys.
Best,
Damien

It is clear that measurement is one aspect of the issue and both genders should be initiated towards programs and projects in terms of awareness and HIV/AIDS prevention. However, regardless of the strategy utilized, it is important to consider societal and cultural customs and behaviours that cannot be altercated though multilateral, bilateral or private programs and projects. It's quite easy to throw in methodologies to it and hope for the best working one to prevail, but you must acknowledge your constraints and the things that you do not have the power to change and work with it. Every initiative should be specifically regionally and locally catered in order to capture both genders and work with their everyday social relations. There is no one-size fits all initiative, especially when you are dealing with tradition and culture. This goes back to what Abdulrahman Abdu said in one of the previous posts about culture and tradition. It is important to understand these and work with it in order to fight existing patterns of violence and the HIV/AIDS pandemic. This does not mean that you must change the culture, but understand it and work with it.

I'm not sure I understand your last sentence but anyway, having been working for a behaviour change communication strategy since 2006, I've come to endorse the observation that at the end of the day the success or failure of global efforts to prevent HIV/AIDS depends on on thel willingness and ability of individuals to behave in certain ways—to avoid risk, to seek counseling and HIV testing, to take appropriate preventive measures, and to adhere to recommended treatment regimens. The organisation I've worked for is called Modelling and Reinforcement to Combat HIV/AIDS (MARCH) Zambia in the Southern and Western Provinces of Zambia. Fundamentally, MARCH Zambia combines Modelling/Showing characters in a radio serial drama transitioning from risky behavioural traits to non risky ones over time and Reinforcement through interpersonal communication and mobilization at the community level to link them to services or simply talk with them to keep encouraging them in their efforts to alter certain behaviours. When the programme started in 2006, it was preceded by a formative research in seven (7) specific locations and just as an example, one of the key issues we sought to address was sexual cleansing in Southern Province. Traditionally, it's believed that a widow has her husband's ghost hovering around her until she is cleansed or will have the worst of things happening to her. Now despite other cleansing options like simply taking a concoction of herbs and kuchuta (man simply rolling over the widow) most people usually chose sexual intercourse as the cleansing mode because they believed and others still believe that it is the most effective. Most chiefs, if not all, in Southern Province have banned the practice, encouraging the use of other options but anecdotal data from reinforcement activities in 2009 showed that some people knew of women, who after agreeing to be cleansed non sexually still went ahead and had sex with unsuspecting men just to 'transfer' the ghost. Another example is the culture of silence in marriage...on face value, people assume men cheat more than women there are married women who say they prefer to have 'side kicks' for sex because if they complained that they were not being sexually satisfied, the man would say they are not 'cultured' which could be grounds for divorce. It's not that these people do not know that such puts them at a higher risk of HIV infection, they do. Organisations aimed at fighting HIV/AIDS exist in hundreds but they are not well coordinated - even in their specific localities.

When did the HIV epidemic start? Did any peace corp volunteer bring aids into the US? Apart from radios and cellphones, etc., people in the villages of Africa have live the same lifestyles from time immemorial. If so was any slave that was imported to the Americas infected with HIV or AIDS virus? Begin to think, please!
Why is it such a strange coincidence that HIV/AIDS is most prevalent in the best lands of Africa namely the east and southern regions where white people occupied and would not give up. It is in these parts that this plague has done its worst devastation.
Has no one in authority ever read that some ten or twelve years ago a reputable paper like the 'Philadelphia Inquirer' wrote that HIV, which causes AIDS was manufactured (something to that effect) in the Wister Institute in Philadelphia, Pennsylvania. If this is so it is a biological weapon of mass destruction. Whoever used it in Africa should be brought to book. If HIV has been endemic in Africa I think that Albert Schweitzer should have known about it. Did anybody read from local Ugandan newspapers then that contaminated blood was sent from Europe to Uganda, the pearl of Africa, which became the AIDS capital of the world.
After independence, the West made sure that Africa remained poor so they strangled it with debt and unworkable programmes in the name of Aid in order to gender hopelessness and helplessness, and by also entrenching dictatorships, and lastly making Africa sick with AIDS. In the nineteen seventies I read from in a British newspaper that the father of the National Party said with one hand we shall raise the torch[ for all to see] and with the other we will life up the grate and let out the sewer rats. May the double standard and hypocrisy of the West perish and may Africa rise up from its ashes like the phoenix. SO LET IT BE, AMEN!.

In spite of Nigeria’s oil wealth (the nation is the 6th oil producing nation in the world), the poor constitute about 70% of the Nigerian population. And recent report by the United Nations Development Programme (UNDP) shows Nigeria as the 26th poorest nation in the world (The Guardian, July 26, 2002; also see Dike, October 6, 2002). With the vast mineral, oil, water, land and human resources, many Nigerians live on less than $1.00 (one U.S. dollar) a day. Is this statistics not bad enough to wake the nation’s political leaders from slumber? Who are the poor in Nigeria? Poverty has narrow and broad definitions, partly because it is a physical matter, and partly because poverty is relative. It is physical because one can note its effects on those afflicted by it. And it is relative because a poor person in one country may not be perceived as such in another country. However, the poor are those that ‘have limited and insufficient food, poor clothing [live in] crowded…and dirty shelter…’ (Galbraith 1955), cannot afford medical care and recreation; cannot meet family and community obligations and other necessities of life. And people are "poverty-stricken when their income, even if adequate for survival, falls markedly behind" the average obtainable in their immediate community (Galbraith 1955). Poverty is a serious issue in Nigeria, because many people are struggling daily for survival without assistance from the State. Worse still, the nation does not have any guideline to measure the construct, which are available in some countries. For instance, in the US the 1995 ‘official federal policy notion of poverty guidelines ‘carry precise dollar amounts’ of about $15,150 for a family of four. Poverty guidelines, which are issued by The Department of Health and Human Services, determine financial eligibility for federal programs and household incomes for basic necessities. And any family whose income is below the set amount is considered living below the poverty line (journalofpoverty.org). The poverty threshold, which is the statistical version of the poverty guidelines, is used by the ‘Census Bureau’ to calculate the number of persons in poverty in the United States, States or Regions (Schwarz Oct.1998; UNDP 2002). Thus, a poor person could not afford the life style a rich individual would regard as the minimum for decency and acceptable in a particular community. However, no precise definition is really needed in Nigeria for us to understand what poverty is, as poverty is indelible on those afflicted by it. The poor are those who cannot afford decent food, medical care, recreation, decent shelter and clothe; meet family and community obligations, and other necessities of life. With this, it is not surprising that poverty is regarded as a form of oppression (UNDP Conference Report, 15-17 March 2001). The Webster’s New Twentieth Century Dictionary depicts poverty as the condition or quality of being poor, need, indigence, and lack of means of substance. It is also deficiency in necessary properties or desirable qualities, or in a specific quality, etc. And the Journal of Poverty notes that poverty means more than being impoverished and more than lacking financial means. It is "an overall condition of inadequacy, lacking and scarcity, and destitution and deficiency of economic, political, and social resources." This is a broader perspective of poverty, which reflects its true dimensions. Therefore, people are living in poverty, ‘if their income and resources (material, cultural and social) are so inadequate as to preclude them from having a standard of living which is regarded as acceptable’ by their society generally (Ireland: NAPS, 1997). Because of the effects of her underdevelopment and corruption, the poor are found both in rural and urban settings in Nigeria, with different categories of poverty. Reports show that HIV/AIDS contribute to the worsening poverty situation at household level in many countries in Africa. For instance, a November 2001 Government of Nigeria sentinel survey reported that Nigeria had "5.8% HIV prevalence rate." And the United Nations ranked Nigeria as the forth-worst affected country in 1999 based on the number of HIV infections. With life expectancy of 55 years, illiteracy rate of 50%, and under-five mortality of 143 per 1, 000 live birth, HIV/AIDS affects over 2.7 million people in Nigeria (USAID, 2002). And with poor economic performance, corruption, the paltry expenditure of $0.03 per capita funding for HIV/AIDS as of 1996, and the citizen’s inability to pay for treatment once infected, the number of HIV/AIDS in Nigeria is expected to increase in future (UNAIDS 1999; see Hecht (PSR) UNAIDS 2000). For that a public awareness campaign should be intensified to educate the masses on ways to prevent the spread of the epidemic.